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0 0 <br /> Please printrn-type.Iron"designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> 1.Generator k0 Number - 2.Page n30'' <br /> of 3.EmergeBcyR 1lwotna one 4.M!rifest Tracking GNumber <br /> UNIFORM HAZARDOUS C A i-O p 0 2 6 5 3 ?5 1- 1sswl) J J K <br /> WASTE MANIFEST <br /> S.Generalpfs Nama @r �A?9ng!?Qdress Generators Site Address(if d'dferem Man mailing address) <br /> Gil'.'. 'i�i::i'327 <br /> Generators Phone: EPAI <br /> 6.Transportprn,4�o�npatly.�.Jy{rr��0td>y!EtJT:+_gc�:i��l"F:-� �WN"!2 S e 7 7 0 3£: <br /> 7.Transporter 2 Company Name U.S.EPA IO Number <br /> U.S.EPA ID Number <br /> B.Designai 134 "uata1287 EPZ�WAN106 AVENUE <br /> iYu!JItS. <br /> PARI!EF C.P. 93644 G AL 0 0 0 10.2 7 5 ? <br /> Facifi 'a Phone: <br /> ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Herod Class,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes <br /> HM and Packing GrouP(d any)) No. Type Quantity WI1Vd. <br /> 1, M t 1lvu:zlit uxav sl tc.r 1.0 - 133 <br /> S(!t.UTIONS! <br /> 001 TT G -- --`- <br /> rz <br /> z 2. <br /> World Oil-San JDa urn LLC <br /> 3. has the appropriate permits to r ceive <br /> your waste, and has received th waste. <br /> F <br /> C <br /> 14.Special Handling Instructions and Additional Info nation <br /> 7YERGENC"COri7ACT:CHEWTREC 1-M-424-9390'APPROPRI EPERSOiiALPROTECTIVEEQUiPMffaiEMERGENCY <br /> ,:NEpa}TRECAOCz424-830p " <br /> 15. GENERATOR'SIOFFERORS CERTIFICATION: I hereby declare that the contend of this consignment M and accurately dece�cnbed above by the prope Shipping name,and are classified.packaged, <br /> marked and lab'eledlplacemed,and are in all respects in proper wndition for transport acooming to apPllrab inrertatienal and Mn reguns.If export sMpment and I am the Primary <br /> Exponer,E ceroy that the contents of thiscpnsignment conform to Me terms of the attached EPAAtcmowled� t d Consent. / <br /> I certify tl0t 8)e waste minimization,°M.2ient identified in 4o CFR 26217 a)(B I am a large quanti�y3enerato�or(b),(dl am a small quanny enera f(is We. Year <br /> sinamore <br /> Genrerator4loNetdrs dntedrtyped Namet,! [ tjPit, �1 <br /> 16.International Shipments <br /> f— ❑Impar to U.S. ❑Exporttran U.S. \�i Pod oeaving U.S.:z Transporter sgnalme(for exports only): Daa leaving U.S. <br /> K 17.Transporter Acknowledgment Of Receipt OfWerals inth Year. , <br /> H" Transporters PrnteM _Name "f_ Fi" / / r SignaWre,,r h'°�r= - <br /> Z Transporter 2 Phntedrryped Name signature Monts - Day Year <br /> K <br /> r— <br /> p ♦ 18.Discrepancy <br /> 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partiat Rejection ❑Full Rejection <br /> ,x ManSest Reference Number. <br /> ~ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> e LL Facility's Phone: Month Day Year <br /> 18c.Signature of Alternate Facility for Generator) <br /> 6 <br /> 2 <br /> a � 19.Hazardous Waste Report Management Method Codes(.e.,codes Ierhaumous waste Vestment,disposal,and recycling systems) <br /> wI T 2 a 4. <br /> s V—Prnn <br /> ated Facility Owner of Oparater.Certification of receipt of hazardous materials covered by the manifest except ss noted in Ileo118a <br /> adNama SgnatureMonth ay-22e0-22(Rev.3-OS) Previous ediUansare obsolete. y"' DE_ ATED F/tCILITYTO GENERATOR <br />